An age-friendly approach to primary care in an academic health system.

BACKGROUND: Age-friendly care, addressing what matters most, medications, mentation, and mobility, is a successful model for improving older adult care. We describe the initial outcomes of age-friendly care implementation in five primary care clinics in an academic health system. METHODS: In partnership with a regional quality improvement (QI) organization, we used practice facilitation to implement age-friendly care from July 2020 to June 2023. Clinic workflows and electronic health record (EHR) templates were modified to capture six QI measures for patients ≥65 years: Documenting what matters most to patients Advance care planning (ACP) Annual cognitive screening Caregiver referral to dementia community resources Fall-risk screening Co-prescription of opioid and sedative-hypnotic drugs Providers were alerted if patients had positive screens and given support tools for clinical decision-making. QI measures from January-June 2023 were compared to the year prior to implementation. Providers and staff were interviewed about implementation barriers and facilitators. RESULTS: All six measures improved in Geriatrics and and other clinics showed improvement in ACP and cognitive screening. All clinics had high fall-risk screening rates (≥85%). The least improved measure was co-prescription of opioids and sedative-hypnotics with co-prescription rates ranging from 7% to 39%. Implementation hinged on leadership prioritization, practice facilitator guidance, clinical team buy-in, EHR functionality, and clinical performance review. Three clinics received Age-Friendly Health System recognition. CONCLUSIONS: A QI approach using practice facilitation and EHR templates improved some but not all age-friendly care measures. Future interventions will focus on training in high-risk medication tapering and elicitation of health goals.

Informing the development of the coaching online and community health (COACH) program: a qualitative study of clubhouse members living with serious mental illness.

Health and wellness interventions addressing risk factors for early mortality among individuals with serious mental illness have demonstrated success and can be further augmented with digital technology. These programs may be suitable for delivery in psychosocial rehabilitation clubhouses, especially given many services have transitioned to digital platforms during the pandemic. This qualitative study aimed to: (a) explore clubhouse members' experiences engaging with the virtual clubhouse platform, and their preferences for accessing digital wellness and health promotion content; and, (b) gauge members' interest in an online peer-driven lifestyle intervention and their suggestions for program design. This study was guided by a community-based participatory action research framework. Ten focus groups were conducted with clubhouse members. Focus groups were coded and analyzed thematically by trained clubhouse members and the research team. Thirty-three members participated in the focus groups. Participants expressed the importance of having technical support from staff; that one-on-one support and consistent communication are important to keep them engaged in health and wellness programming; and described mixed views about use of the virtual platform, but generally were open to engaging in lifestyle intervention programming virtually. Participants who joined the clubhouse during the pandemic expressed feeling overwhelmed by in-person gatherings, and were especially interested in opportunities for remote participation. This study can inform health and wellness programming for delivery on the virtual clubhouse platform for members. The taxonomy of codes, created to generate a framework with recommendations, will inform the design of a virtual health and wellness intervention.

This study investigates people with mental illness's interest in an online program to improve their heart health and fitness through a clubhouse which they are a member of. Previous programs have had success improving the heart health and fitness of people with mental illness and adapting these programs to be accessible online can expand their impact. Thirty-three individuals participated in 10 focus groups and expressed the importance of having help from when accessing technology; that one-on-one support and communication would increase their participation in these programs; and described mixed views about use of online programs, but generally were open to an online program to increase heart health and fitness.

Multifunctional Composite Hydrogels for Bacterial Capture, Growth/Elimination, and Sensing Applications.

Hydrogels are cross-linked networks of hydrophilic polymer chains with a three-dimensional structure. Owing to their unique features, the application of hydrogels for bacterial/antibacterial studies and bacterial infection management has grown in importance in recent years. This trend is likely to continue due to the rise in bacterial infections and antimicrobial resistance. By exploiting their physicochemical characteristics and inherent nature, hydrogels have been developed to achieve bacterial capture and detection, bacterial growth or elimination, antibiotic delivery, or bacterial sensing. Traditionally, the development of hydrogels for bacterial/antibacterial studies has focused on achieving a single function such as antibiotic delivery, antibacterial activity, bacterial growth, or bacterial detection. However, recent studies demonstrate the fabrication of multifunctional hydrogels, where a single hydrogel is capable of performing more than one bacterial/antibacterial function, or composite hydrogels consisting of a number of single functionalized hydrogels, which exhibit bacterial/antibacterial function synergistically. In this review, we first highlight the hydrogel features critical for bacterial studies and infection management. Then, we specifically address unique hydrogel properties, their surface/network functionalization, and their mode of action for bacterial capture, adhesion/growth, antibacterial activity, and bacterial sensing, respectively. Finally, we provide insights into different strategies for developing multifunctional hydrogels and how such systems can help tackle, manage, and understand bacterial infections and antimicrobial resistance. We also note that the strategies highlighted in this review can be adapted to other cell types and are therefore likely to find applications beyond the field of microbiology.

Detection of selective androgen receptor modulators (SARMs) in serum using a molecularly imprinted nanoparticle surface plasmon resonance sensor.

Selective Androgen Receptor Modulators (SARMs) are a fairly new class of therapeutic compounds that act upon the androgen receptor. They proffer similar anabolic properties to steroids, but with a much-reduced androgenic profile. They have become a popular substance of abuse in competitive sport. Being relatively new, detection systems are limited to chromatographic methods. Here we present a surface plasmon resonance sensor for three commonly-used SARMS, Andarine, Ligandrol and RAD-140, using high-affinity molecularly imprinted nanoparticles (nanoMIPs) as the recognition element. Synthesised nanoMIPS exhibited dissociation constant (KD) values of 29.3 nM, 52.5 nM and 75.1 nM for Andarine, Ligandrol and RAD-140 nanoMIPs, respectively. Cross-reactivity of the particles was explored using the alternative SARMs, with the nanoMIPs demonstrating good specificity. Fetal Bovine Serum (FBS) was used to assess the ability of the SPR-based nanoMIP sensor to detect the target compounds in a comparable biological matrix, with observed KD values of 12.3 nM, 31.9 nM and 28.1 nM for Andarine, Ligandrol and RAD-140 nanoMIPs, respectively. Theoretical limits of detection (LoD) were estimated from a calibration plot in FBS and show that the nanoMIP-based sensors have the potential to theoretically measure these SARMs in the low to sub nM range. Crucially these levels are below the minimum required performance limit (MRPL) set for these compounds by WADA. This study highlights the power of modern molecular imprinting to rapidly address required molecular recognition for new compounds of interest.

A molecularly imprinted polymer nanoparticle-based surface plasmon resonance sensor platform for antibiotic detection in river water and milk.

Using a solid-phase molecular imprinting technique, high-affinity nanoparticles (nanoMIPs) selective for the target antibiotics, ciprofloxacin, moxifloxacin, and ofloxacin have been synthesised. These have been applied in the development of a surface plasmon resonance (SPR) sensor for the detection of the three antibiotics in both river water and milk. The particles produced demonstrated good uniformity with approximate sizes of 65.8 ± 1.8 nm, 76.3 ± 4.1 nm, and 85.7 ± 2.5 nm, and were demonstrated to have affinities of 36.2 nM, 54.7 nM, and 34.6 nM for the ciprofloxacin, moxifloxacin, and ofloxacin nanoMIPs, respectively. Cross-reactivity studies highlighted good selectivity towards the target antibiotic compared with a non-target antibiotic. Using spiked milk and river water samples, the nanoMIP-based SPR sensor offered comparable affinity with 66.8 nM, 33.4 nM, and 55.0 nM (milk) and 39.3 nM, 26.1 nM, and 42.7 nM (river water) for ciprofloxacin, moxifloxacin, and ofloxacin nanoMIPs, respectively, to that seen within a buffer standard. Estimated LODs for the three antibiotic targets in both milk and river water were low nM or below. The developed SPR sensor showed good potential for using the technology for the capture and detection of antibiotics from food and environmental samples.

Mind-Body Integrative Health (MBIH) Interventions for Sleep among Adolescents: A Scoping Review of Implementation, Participation and Outcomes.

Adolescents get insufficient sleep, adversely affecting health. Mind-body integrative health interventions for adolescents have been shown to reduce stress, a barrier to good sleep. This scoping review aimed to synthesize mind-body integrative health interventions for adolescents, how interventions were implemented, who was reached. A systematic search of four online databases was conducted. Randomized, quasi-experimental, and single-group designs with participants ages 10-24 years were included. Twelve studies covering 10 interventions using mindfulness, qigong, aromatherapy, or yoga were identified. Participants were predominantly female; only one study reported participants' race or ethnicity (81% non-Hispanic white). Most (n=6) interventions were delivered in groups, and half reported significant improvements in subjective sleep quality. Mindfulness-based stress reduction and mindfulness-based cognitive therapy were the most commonly used modalities, with reported impact on sleep outcomes measured objectively. The two interventions that found statistically significant, moderate improvements in objectively-measured sleep onset latency and sleep efficiency were of higher intensity and used mindfulness. Four interventions were self-directed; participants in these struggled with adherence; significant impacts on sleep were not found. While findings were mixed, stemming in part from the quality of the underlying studies, this review identified several promising features of interventions, including using mindfulness, ensuring sufficient intervention dose, and targeting interventions towards adolescents with poor sleep at baseline (rather than a general population of adolescents). The findings suggests that sleep interventions for adolescents may improve psychological well-being as an intermediate effect, as sleep improvements were observed mostly among participants with poor sleep quality or anxiety symptoms at baseline. This review identified several gaps in the literature. Despite documented racial and ethnic disparities in sleep quality among adolescents, published evidence of mind-body integrative health-based sleep interventions among Black and Latinx adolescents is lacking. None of the studies in this review assessed developmental stage or age differences, despite documented differences in sleep across age groups of adolescents. These two gaps in the evidence should be addressed in future intervention research.

Generation of High-Affinity Aptamer-MIP Hybrid Nanoparticles.

Aptamers and molecularly imprinted polymers (MIPs) are two leading technologies used for the development of protein biomimetics. By combining the two technologies, a new hybrid class of materials can be created, which utilizes the interesting characteristics of both recognition materials, while negating several of their drawbacks. This chapter describes the protocol for the synthesis of aptamer-MIP hybrid nanoparticles. These materials exhibit exceptional affinity (into the nM range) and selectivity for their target template. They can be developed for a wide range of targets, while exhibiting excellent robustness, solubility, and flexibility in use. These are a new class of recognition materials with the potential for use as drug delivery vectors, as well as use within sensing and recognition assays.

Application of comprehensive 2D chromatography in the anti-doping field: Sample identification and quantification.

Anti-doping analysis requires an exceptional level of accuracy and precision given the stakes that are at play. Current methods rely on the application of chromatographic techniques linked with mass spectrometry to provide this. However, despite the effectiveness of these techniques in achieving good selectivity and specificity, some issues still exist. In order to reach the minimum required performance level as set by WADA, labs commonly use selective monitoring by quadrupole mass spectrometry. This can be potentially fooled through the use of masking agents or by moving the peaks, as often only a small portion of the spectrum is used for analysis. Further issues exist in the inability to detect new or modified compounds, or to reanalyse samples/spectra. One technique that could overcome these problems is that of comprehensive 2D chromatography. Here a second separation column is employed to generate greater separative power. Compared to conventional separation, GCxGC allows for a greater peak capacity (i.e., number of peaks that can be resolved within a given time) and greater separation of coeluting compounds, which makes the technique promising for the complex task required in anti-doping. When combined with Time of Flight Mass Spectrometry this technique demonstrates vast potential allowing for full mass range datasets to be obtained for retroactive analysis. Similarly, LCxLC provides improvements in resolving power compared to its 1D counterpart and can be used both online as part of the analysis or offline solely as a purification step. In this review we summarise the work in this field so far, how comprehensive chromatography has been applied to anti-doping studies, and discuss the future application for this technique.

Increased cognitive workload evokes greater neurovascular coupling responses in healthy young adults.

Understanding how the brain allocates resources to match the demands of active neurons under physiological conditions is critically important. Increased metabolic demands of active brain regions are matched with hemodynamic responses known as neurovascular coupling (NVC). Several methods that allow noninvasive assessment of brain activity in humans detect NVC and early detection of NVC impairment may serve as an early marker of cognitive impairment. Therefore, non-invasive NVC assessments may serve as a valuable tool to detect early signs of cognitive impairment and dementia. Working memory tasks are routinely employed in the evaluation of cognitive task-evoked NVC responses. However, recent attempts that utilized functional near-infrared spectroscopy (fNIRS) or transcranial Doppler sonography (TCD) while using a similar working memory paradigm did not provide convincing evidence for the correlation of the hemodynamic variables measured by these two methods. In the current study, we aimed to compare fNIRS and TCD in their performance of differentiating NVC responses evoked by different levels of working memory workload during the same working memory task used as cognitive stimulation. Fourteen healthy young individuals were recruited for this study and performed an n-back cognitive test during TCD and fNIRS monitoring. During TCD monitoring, the middle cerebral artery (MCA) flow was bilaterally increased during the task associated with greater cognitive effort. fNIRS also detected significantly increased activation during a more challenging task in the left dorsolateral prefrontal cortex (DLPFC), and in addition, widespread activation of the medial prefrontal cortex (mPFC) was also revealed. Robust changes in prefrontal cortex hemodynamics may explain the profound change in MCA blood flow during the same cognitive task. Overall, our data support our hypothesis that both TCD and fNIRS methods can discriminate NVC evoked by higher demand tasks compared to baseline or lower demand tasks.

Application of molecularly imprinted polymers in the anti-doping field: sample purification and compound analysis.

The problem posed by anti-doping requirements is one of the great analytical challenges; multiple compound detection at low ng ml-1 levels from complex samples, with requirements for exceptional confidence in results. This review surveys the design, synthesis and application of molecularly imprinted polymers (MIPs) in this field, focusing on the templating of androgenous anabolic steroids (AASs), as the most commonly abused substances, but also other WADA prohibited substances. Commentary on the application of these materials in detection, clean-up and sensing is offered, alongside views on the future of imprinting in this field.

Assessment of age-related decline of neurovascular coupling responses by functional near-infrared spectroscopy (fNIRS) in humans.

Preclinical studies provide strong evidence that age-related impairment of neurovascular coupling (NVC) plays a causal role in the pathogenesis of vascular cognitive impairment (VCI). NVC is a critical homeostatic mechanism in the brain, responsible for adjustment of local cerebral blood flow to the energetic needs of the active neuronal tissue. Recent progress in geroscience has led to the identification of critical cellular and molecular mechanisms involved in neurovascular aging, identifying these pathways as targets for intervention. In order to translate the preclinical findings to humans, there is a need to assess NVC in geriatric patients as an endpoint in clinical studies. Functional near-infrared spectroscopy (fNIRS) is a non-invasive neuroimaging technique that enables the investigation of local changes in cerebral blood flow, quantifying task-related changes in oxygenated and deoxygenated hemoglobin concentrations. In the present overview, the basic principles of fNIRS are introduced and the application of this technique to assess NVC in older adults with implications for the design of studies on the mechanistic underpinnings of VCI is discussed.

Synthesis of Pd/Ru Bimetallic Nanoparticles by Escherichia coli and Potential as a Catalyst for Upgrading 5-Hydroxymethyl Furfural Into Liquid Fuel Precursors.

Escherichia coli cells support the nucleation and growth of ruthenium and ruthenium-palladium nanoparticles (Bio-Ru and Bio-Pd/Ru NPs). We report a method for the synthesis of these monometallic and bimetallic NPs and their application in the catalytic upgrading of 5-hydroxymethyl furfural (5-HMF) to 2,5 dimethylfuran (DMF). Examination using high resolution transmission electron microscopy with energy dispersive X-ray microanalysis (EDX) and high angle annular dark field (HAADF) showed Ru NPs located mainly at the cell surface using Ru(III) alone but small intracellular Ru-NPs (size ∼1-2 nm) were visible only in cells that had been pre-"seeded" with Pd(0) (5 wt%) and loaded with equimolar Ru. Pd(0) NPs were distributed between the cytoplasm and cell surface. Cells bearing 5% Pd/5% Ru showed some co-localization of Pd and Ru but chance associations were not ruled out. Cells loaded to 5 wt% Pd/20 wt% Ru showed evidence of core-shell structures (Ru core, Pd shell). Examination of this cell surface material using X-ray photoelectron spectroscopy (XPS) showed Pd(0) and Pd(II) and Ru(IV) and Ru(III), with confirmation by analysis of bulk material using X-ray absorption near edge structure (XANES) and extended X-ray absorption fine structure (EXAFS) analyses. Both Bio-Ru NPs and Bio-Pd/Ru NPs were active in the conversion of 5-HMF into 2,5-DMF but commercial Ru on carbon catalyst outperformed 5 wt% bio-Ru by fourfold. While 5 wt% Pd/20 wt% Ru achieved 20% yield of DMF the performance of the 5 wt% Pd/5 wt% Ru bio-catalyst was higher and comparable to the commercial 5 wt% Ru/C catalyst in a test reaction using commercial 5-HMF (>50% selectivity). 5-HMF was prepared by thermochemical hydrolysis of starch and cellulose with solvent extraction of 5-HMF into methyltetrahydrofuran (MTHF). Here, with MTHF as the reaction solvent the commercial Ru/C catalyst had little activity (100% conversion, negligible selectivity to DMF) whereas the 5 wt% Pd/5 wt% Ru bio-bimetallic gave 100% conversion and 14% selectivity to DMF from material extracted from hydrolyzates. The results indicate a potential green method for realizing increased energy potential from biomass wastes as well as showing a bio-based pathway to manufacturing a scarcely described bimetallic material.

Age-related impairment of neurovascular coupling responses: a dynamic vessel analysis (DVA)-based approach to measure decreased flicker light stimulus-induced retinal arteriolar dilation in healthy older adults.

Aging is a major risk factor for vascular cognitive impairment and dementia (VCID). Recent studies demonstrate that cerebromicrovascular dysfunction plays a causal role in the development of age-related cognitive impairment, in part via disruption of neurovascular coupling (NVC) responses. NVC (functional hyperemia) is responsible for adjusting cerebral blood flow to the increased energetic demands of activated neurons, and in preclinical animal models of aging, pharmacological restoration of NVC is associated with improved cognitive performance. To translate these findings, there is an increasing need to develop novel and sensitive tools to assess cerebromicrovascular function and NVC to assess risk for VCID and evaluate treatment efficacy. Due to shared developmental origins, anatomical features, and physiology, assessment of retinal vessel function may serve as an important surrogate outcome measure to study neurovascular dysfunction. The present study was designed to compare NVC responses in young (< 45 years of age; n = 18) and aged (> 65 years of age; n = 11) healthy human subjects by assessing flicker light-induced changes in the diameter of retinal arterioles using a dynamic vessel analyzer (DVA)-based approach. We found that NVC responses in retinal arterioles were significantly decreased in older adults as compared with younger subjects. We propose that the DVA-based approach can be used to assess NVC, as a surrogate cerebromicrovascular outcome measure, to evaluate the effects of therapeutic interventions in older individuals.

Upconversion of Cellulosic Waste Into a Potential "Drop in Fuel" via Novel Catalyst Generated Using Desulfovibrio desulfuricans and a Consortium of Acidophilic Sulfidogens.

Biogas-energy is marginally profitable against the "parasitic" energy demands of processing biomass. Biogas involves microbial fermentation of feedstock hydrolyzate generated enzymatically or thermochemically. The latter also produces 5-hydroxymethyl furfural (5-HMF) which can be catalytically upgraded to 2, 5-dimethyl furan (DMF), a "drop in fuel." An integrated process is proposed with side-stream upgrading into DMF to mitigate the "parasitic" energy demand. 5-HMF was upgraded using bacterially-supported Pd/Ru catalysts. Purpose-growth of bacteria adds additional process costs; Pd/Ru catalysts biofabricated using the sulfate-reducing bacterium (SRB) Desulfovibrio desulfuricans were compared to those generated from a waste consortium of acidophilic sulfidogens (CAS). Methyl tetrahydrofuran (MTHF) was used as the extraction-reaction solvent to compare the use of bio-metallic Pd/Ru catalysts to upgrade 5-HMF to DMF from starch and cellulose hydrolyzates. MTHF extracted up to 65% of the 5-HMF, delivering solutions, respectively, containing 8.8 and 2.2 g 5-HMF/L MTHF. Commercial 5% (wt/wt) Ru-carbon catalyst upgraded 5-HMF from pure solution but it was ineffective against the hydrolyzates. Both types of bacterial catalyst (5wt%Pd/3-5wt% Ru) achieved this, bio-Pd/Ru on the CAS delivering the highest conversion yields. The yield of 5-HMF from starch-cellulose thermal treatment to 2,5 DMF was 224 and 127 g DMF/kg extracted 5-HMF, respectively, for CAS and D. desulfuricans catalysts, which would provide additional energy of 2.1 and 1.2 kWh/kg extracted 5-HMF. The CAS comprised a mixed population with three patterns of metallic nanoparticle (NP) deposition. Types I and II showed cell surface-localization of the Pd/Ru while type III localized NPs throughout the cell surface and cytoplasm. No metallic patterning in the NPs was shown via elemental mapping using energy dispersive X-ray microanalysis but co-localization with sulfur was observed. Analysis of the cell surfaces of the bulk populations by X-ray photoelectron spectroscopy confirmed the higher S content of the CAS bacteria as compared to D. desulfuricans and also the presence of Pd-S as well as Ru-S compounds and hence a mixed deposit of PdS, Pd(0), and Ru in the form of various +3, +4, and +6 oxidation states. The results are discussed in the context of recently-reported controlled palladium sulfide ensembles for an improved hydrogenation catalyst.

Age-related decline in peripheral vascular health predicts cognitive impairment.

Preclinical studies demonstrate that generalized endothelial cell dysfunction and microvascular impairment are potentially reversible causes of age-related vascular cognitive impairment and dementia (VCID). The present study was designed to test the hypothesis that severity of age-related macro- and microvascular dysfunction measured in the peripheral circulation is an independent predictor of cognitive performance in older adults. In this study, we enrolled 63 healthy individuals into young (< 45 years old) and aged (> 65 years old) groups. We used principal component analysis (PCA) to construct a comprehensive peripheral vascular health index (VHI) encompassing peripheral microvascular reactivity, arterial endothelial function, and vascular stiffness, as a marker of aging-induced generalized vascular dysfunction. Peripheral macrovascular and microvascular endothelial function were assessed using flow-mediated dilation (FMD) and laser speckle contrast imaging tests. Pulse waveform analysis was used to evaluate the augmentation index (AIx), a measure of arterial stiffness. Cognitive function was measured using a panel of CANTAB cognitive tests, and PCA was then applied to generate a cognitive impairment index (CII) for each participant. Aged subjects exhibited significantly impaired macrovascular endothelial function (FMD, 5.6 ± 0.7% vs. 8.3 ± 0.6% in young, p = 0.0061), increased arterial stiffness (AIx 29.3 ± 1.8% vs 4.5 ± 2.6% in young, p < 0.0001), and microvascular dysfunction (2.8 ± 0.2 vs 3.4 ± 0.1-fold change of perfusion in young, p = 0.032). VHI showed a significant negative correlation with age (r = - 0.54, p < 0.0001) and CII significantly correlated with age (r = 0.79, p < 0.0001). VHI significantly correlated with the CII (r = - 0.46, p = 0.0003). A decline in peripheral vascular health may reflect generalized vascular dysfunction and predict cognitive impairment in older adults.

Efficacy of light-protective additive packaging in protecting milk freshness in a retail dairy case with LED lighting at different light intensities.

Light emitting diodes (LED) are rapidly developing as dominant lighting systems in dairy retail cases. Bright light is typically chosen to best exhibit milk products. However, high intensity LED lighting may create high potential for detrimental oxidation and destroying milk freshness. In this study, we investigated the interaction between LED light intensity, exposure time, and packaging material on limiting milk oxidation and protecting milk freshness and vitamins. Within 4 h of LED light exposure at an intensity as low as 1068 lx, light-induced oxidation occurred on 2% milkfat milk with commercial packaging including glass and translucent high-density polyethylene (HDPE) bottles. Higher light intensity (>4094 lx) and longer light exposure time (>24 h) rapidly increased the oxidation rate in milk. Polyethylene terephthalate (PET) packaging with lower oxygen permeability rate effectively reduced (P < 0.05) vitamin A degradation under low light intensity within 24 h. A combination of light-protective additive (TiO2) and oxygen barrier material (PET) successfully reduced (P < .05) the loss of dissolved oxygen and riboflavin, and decreased the formation of final oxidation products in milk, as measured by thiobarbituric reactive substances (TBARS), when exposed to high light intensity within 24 h. Lower LED light intensity in retail case was preferred by 50% of participants in a visual acceptance test; consumers are willing to consider pigmented packaging with limited visibility. Results of this study provides guidance for dairy industry in choosing appropriate LED lighting conditions and packaging to adequately display the milk products as well as minimize the degradation of milk nutrients and flavor.